AUTONOMIC STANDARDS ASSESSMENT FORM Anatomic Diagnosis: (Supraconal □, Conal □, Cauda Equina □)

Patient Name: _________________

General Autonomic Function Lower Urinary Tract, Bowel and Sexual Function
System/Organ Findings Abnormal conditions Check System/Organ Score
mark Lower Urinary Tract
Autonomic Normal Awareness of the need to empty the bladder
control of the Abnormal Bradycardia
heart Ability to prevent leakage (continence)
Tachycardia
Other dysrhythmias Bladder emptying method __________
(specify)
Unknown Bowel
Unable to Sensation of need for a bowel movement
assess
Autonomic Normal Ability to Prevent Stool Leakage (Continence)
control of blood Abnormal Resting systolic blood pressure
pressure below 90 mmHg Voluntary sphincter contraction
Orthostatic hypotension Sexual Function
Autonomic dysreflexia Genital arousal Psychogenic
Unknown (erection or lubrication)
Unable to Reflex
assess Orgasm
Autonomic Normal Ejaculation (male only)
control of Abnormal Hyperhydrosis above lesion Sensation of Menses (female only)
sweating Hyperhydrosis below lesion
Hypohydrosis below lesion 2 = Normal function, 1=Reduced or Altered Neurological Function
Unknown 0=Complete loss of control NT=Unable to assess due to preexisting or
Unable to concomitant problems
assess
Temperature Normal Urodynamic Evaluation
regulation Abnormal Hyperthermia
System/Organ Findings Check
Hypothermia
mark
Unknown
Sensation during filling Normal
Unable to
Increased
assess
Reduced
Autonomic and Normal
Somatic Control Absent
Abnormal Unable to voluntarily breathe
of Broncho- requiring full ventilatory support Non-specific
pulmonary Impaired voluntary breathing Detrusor Activity Normal
System requiring partial vent support Overactive
Voluntary respiration impaired Underactive
does not require vent support Acontractile
Unknown Sphincter Normal urethral closure mechanism
Normal urethral function during voiding
Incompetent
Detrusor sphincter dyssynergia
Non-relaxing sphincter

Date of Injury__________________ Date of Assessment_________________ Examiner________________________

This form may be freely copied and reproduced but not modified (Sp Cord, 2009, 47, 36-43)
This assessment should use the terminology found in the International SCI Data Set
(ASIA and ISCoS - http://www.asia-spinalinjury.org/bulletinBoard/dataset.php)